Selecting a Level of Service based on Medical Decision-Making (MDM) Part II

Monday, May 8, 2023

To determine the appropriate level of an E/M service, it is required to have documentation that satisfies at least two of the three elements – Problem, Data, and Risk. The American Medical Association (AMA) provided this document, Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM), on their website. This guide can be used to select the correct E/M code based on MDM. The code selection should be linked to the specific criteria defined for each code and level.

This edition focuses on data, the second element of medical decision-making (MDM).

Element 2

Data: The second step in the selection process is calculating the amount and complexity of data to be reviewed and analyzed. “Data” is defined as certain data elements that are ordered, reviewed, analyzed, or independently interpreted as further specified in the MDM table in the AMA’s Evaluation and Management guidelines.

Clarifying “Data” Definitions Ordered: A test may normally be performed, but after shared decision-making, the test is not ordered due to risk or necessity. These tests may still be counted in such cases, but considerations must be documented. Ordering a test and reviewing the result(s) as part of the encounter are included in the category of test results.

Analyzed: Tests are counted in the order in which the results are reported (see “Ordered” above). For example, if a test is recurring, it is counted when the result is reported and not when it is ordered. Ordering a test may include those that were considered but not performed after shared decision-making.

Unique: Unique tests do not include overlapping elements and are defined by the CPT® code set. Multiple results of one unique test reviewed at a visit count for one test. A unique source is a clinician in one group or different specialty or unique entity. Reviewing all materials from an unusual source count towards one element of data in medical decision-making.

Independent Historian: An individual that provides a history when the patient is unable to provide a complete or adequate history or when it is determined that the patient’s history needs to be confirmed by another source. The history does not have to be obtained in person but must be obtained directly from an independent source. This does not include translation.

Make sure to document why an independent history is needed.

Independent interpretation: This cannot be included in determining a level of service if the interpretation test is independently reported by the provider reporting the E/M service and must be performed for a test reported by the CPT code. The interpretation should be documented. Appropriate source: An appropriate source is defined as professionals who are not healthcare-related but participate in managing the patient (for example, social workers or lawyers).

American Medical Association. “2023 Evaluation and Management (E/M) Code and Guideline Changes”. 2022. 2023 CPT E/M descriptors and guidelines

In Part III, we’ll look at Risk, the Third element involved in MDM.

 

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